IN 2012, AS SUPERSTORM SANDY RAGED over New York City, Sheri Fink hunkered down with doctors and administrators in the command center of North Shore – LIJ Health System, a group that includes 16 hospitals and several hundred physicians’ practices in the New York and Long Island areas. An executive burst into a meeting with the news that New York University’s Langone Medical Center was on the phone; flooding threatened the hospital’s backup power systems, and NYU was in desperate need of ambulances to transport four critically ill babies from its neonatal intensive care unit before the hospital lost power. As North Shore – LIJ figured out how to get the ambulances to NYU, Fink looked on, dismayed — it was all too familiar, a story that repeated itself as health care facilities across the country struggled to cope with one disaster after another, from hurricanes to wildfires to tornadoes.

Fink’s primary point of reference was New Orleans in August of 2005, and the impact of Hurricane Katrina on the city’s Memorial Medical Center. Forty-five patients died at Memorial during and immediately after Katrina, and forensic experts determined that 23 of them had elevated levels of morphine and other drugs in their systems. Twenty patients were deemed victims of homicide — that they had in effect been killed by their caregivers as the flood waters rose, as the hospital’s primary and backup power failed, as the hope of rescue became increasingly remote, and as reports circulated of an immobilized city descending rapidly into anarchy and violence.

Fink was trained as a physician and scientist — she holds an M.D./Ph.D. in neuroscience from Stanford — and later became a journalist. In 2007, she began investigating the story of what happened at Memorial, and in 2009, The New York Times Magazine and ProPublica published her article "The Deadly Choices at Memorial," which won a Pulitzer Prize for investigative reporting. She followed that in September with her book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, a greatly expanded account of not just what occurred at the hospital, but why and how. Six years in the making, informed in part by more than 500 interviews with hospital personnel, patients, emergency responders, law enforcement representatives, and many more, Five Days is a monumental up-close account of a tragedy that defies easy explanation, just as the moral complexities faced by Memorial’s medical staff defy black-and-white categorization.

Precarious Rescues
Clockwise from above: A patient sorts through her medication while waiting to be airlifted from a badly damaged Memorial Medical Center in New Orleans on September 2, 2005.

A Memorial Medical Center nurse fans patients in the hospital's parking garage as they await helicopter transport. Helicopters hired by the hospital's parent company, Tenet Healthcare Corporation, did not arrive until two days after the streets around Memorial had flooded.

A nurse gives a patient water as hospital staffers carry patients up three flights of stairs from the parking garage to the helipad.

A patient is carried to a waiting helicopter. Some Memorial staffers wondered if the hospital's decrepit helipad would even be able to support the weight of landing aircraft.

A doctor checks a critically ill patient loaded aboard a helicopter for evacuation.

Photographs: Brad Looper / Dallas Morning News/Corbis.

It’s understandable why Fink had a sinking feeling as she watched the Superstorm Sandy drama play out around her. "[North Shore–LIJ] had a highly organized, local command center and was offering proactive and robust assistance not only to its own hospitals but also others in the region," she writes. "Yet, incredibly, just as in the lead-up to Katrina, some staff members said they had never pondered or planned for what they would do in case of a failure of the backup plan to the backup plan — a complete loss of power. This was true not just there, but also in many places where I have reported since Katrina. Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond — our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses."

Five Days directly addresses health care codes and standards in only a few instances, but it should be required reading for the industry nevertheless. Fink tells the story of Memorial through a large cast of characters, and in gripping narrative detail; scenes are painstakingly reconstructed to place the reader squarely in the center of the unfolding action. It’s in those details, and in the how and why of the manner in which things went wrong, where it’s easy to see the codes at work, or where they may need to be strengthened to better match the calamity they were designed to mitigate. Ultimately, Five Days is precisely about the effectiveness of the tools we deploy — codes and standards, emergency procedures, testing and training, and more — to prepare for and manage our response to disaster.

To Fink, the prognosis is not good, especially when it comes to electricity, the lifeblood of the health care industry. "I think we have a remarkably vulnerable health care infrastructure in this country," she told NFPA Journal in a recent interview. "In hospitals, for instance, backup generator systems do not have to keep HVAC systems going, which has been a real problem in a number of circumstances I’ve seen, including Memorial. Also, many backup power systems are still geared to short outage events rather than prolonged outages, and this can be an issue for all kinds of health care facilities."

There were a number of possible reasons why Memorial’s backup generators failed, Fink says. That failure was a point of contention in a civil suit brought by patients, relatives, and others against the hospital and its parent company, Tenet Healthcare Corporation, and the precise cause of the failure varied depending on who was asked. Among the possible contributing factors, Fink says, is that the generators weren’t very robust to begin with, and that testing requirements did not push the generators enough to reveal the kinds of problems that could arise during a prolonged outage.

NFPA codes and standards address these issues through a variety of provisions. NFPA 99, Health Care Facilities, for example, requires a Type 1 or Type 2 essential electrical system [EES] for most health care facilities, including hospitals and nursing homes, according to Jonathan Hart, a fire protection engineer at NFPA. The EES encompasses the entire electrical system, from the generator set to the transfer switches to the system’s various branches. NFPA 99 requires these systems to be Class "X" emergency power supplies, where the number "X" defines the minimum time in hours for which an emergency power supply system is designed to operate at its rated load without being refueled or recharged. "There are specific numbers of hours that can be assigned, but NFPA 99 allows for facilities to make that decision themselves," says Hart.

That decision should be made in conjunction with the facility’s emergency management plan [EMP]. The EMP does not require the emergency power supply to be a Class 96, Hart says; instead, it instructs facilities to identify possible resource shortfalls after 96 hours, including fuel, and to plan for ways to mitigate those shortfalls if they are necessary and feasible. In some states, the EMP includes a list of resources such as available bed space at surrounding facilities, the status of fuel deliveries, and the availability of contractors to perform emergency on-site repairs to generators, HVAC equipment, and other systems.

Fink also finds reasons for cautious optimism. She sees more of a national engagement taking place with the concept of crisis standards of care, which addresses questions of how scarce resources can be allocated and managed in a disaster and how we can avoid those kinds of scarcities to begin with. She offers an example from Memorial: Who should be given priority for spots on a rescue helicopter? "There’s no one way to decide who gets a life-saving resource," she says. "There are a lot of different ways to approach that question."

Despite increased engagement with such issues, gaps persist. "Very few of the doctors I speak to know about the work going on in this area," Fink told Journal. "But in order for these protocols to work, there needs to be more awareness, and a more inclusive input in the creation of these protocols, as well as more research on them."

Building a larger sense of awareness, especially around some of health care’s core vulnerabilities, is also necessary if we want to prompt change, Fink says. "I think there can be a desire to diminish the public’s perception that we are vulnerable, and that’s really unfortunate," she says. "It’s only when the public knows what these vulnerabilities are that it will support the kinds of critical investments necessary to fix them — it’s why the places that tend to act, that do make those investments, are the ones that have gone through a disaster and know what the stakes are for failing to prepare. Organizations like NFPA can perform a great public service by engaging the public with these issues."

One of the heartbreaking aspects of reading Five Days at Memorial is realizing that the hospital’s fate, especially the fate of its intensive-care and long-term acute-care patients, was far from inevitable: what happened did not have to happen. Instead, an accretion of circumstances, events, and decisions—the moments Fink captures with such nuance and clarity — gradually eliminated the hospital staff’s options for what to do with its most vulnerable patients.

Codes and standards, Fink says, can offer a strong defense against the circumstances and forces that hobbled Memorial and made it a worst-case cautionary tale. "Ultimately, the mission of health care standards is to protect us when we are most in need," she says. "We should be proud of the standards we have, but we also need to recognize our vulnerabilities. We don’t want to be a country where hospitals collapse in earthquakes. We need to acknowledge the gaps in our emergency preparedness and make the investments necessary to balance fiscal concerns with a commitment to assist the people who need help the most. We need to look at these problems and ask ourselves what we want to be as a country."

Scott Sutherland is executive editor of NFPA Journal.

"The Sickest Sound"

An excerpt from Sheri Fink’s Five Days at Memorial

A BATTLE WAS under way to keep the generators running. Each of the three teal-colored generators was taller than a typical adult and pumped electricity into a complex circulatory system of feed lines, riser circuits, and transfer switches. Normally an outside company serviced the 750 kW generators, each producing the power of about six engines from one of the year’s most popular cars, a Toyota Camry. The hospital’s maintenance staff did little more than change the oil and run tests once a month in the middle of the night. The tests were brief, in keeping with national codes that treated hospital generators like heart-lung bypass machines used during surgeries, meant to support vital functions for a period of only minutes to hours. Despite the fact that the generators were not built for prolonged work, Memorial’s disaster plans called for them to shore up the hospital for at least three days. They had already been running for two.

None of the Memorial electricians or engineers on-site was a generator mechanic. Earlier, when one of the generator engines had shut down, casting part of the hospital into darkness and sending staff scrambling to move patients, maintenance workers concluded it was overheated. Laboring by flashlight, they added water to the radiator and were able to restart it.

Hours later, the problems multiplied. Low oil pressure appeared to be the cause; the men brought barrels of diesel to try to prime the motors with fresh fuel and restart them. Maintenance men crossed the bridge to the surgery building to retrieve more diesel from a generator there. Some sections of the hospital were losing power. In parts where there was light, it seemed to be dimming, strangling.

Over the years, the original 1926 hospital had received additions, and the electrical system now resembled the blood supply of conjoined twins, separate but overlapping and, as a whole, unique to itself and mysterious.

One generator failed. Unable to restart it, the engineers tried to tie some of the lines it supplied to another generator. They pulled on rubber boots and ran down to the basement, splashing into knee-deep water, then climbed up a few steps to the mezzanine of the core electrical building.

They tried to determine the reason for the partial outages throughout the hospital. The depth of the water offered a clue. About a third of the automatic transfer switches, which allowed the generators to power the hospital when normal utility power was lost, were on a low level of the building, and it looked like they and their associated distribution panels might be submerged, much as plant operations director Eric Yancovich had predicted several months earlier.

Like in a scene from The Poseidon Adventure, the men waded through a narrow hallway bordered by electrical panels and a sign with two lightning bolts that read caution: hazardous voltage inside. Using a flashlight, they located a metal lever with a yellow rubber–coated handle above their heads marked "bypass handle." Praying not to get electrocuted, one flipped it, grafting the load of the nonworking generator to a working one.

Soon a gauge showed that the working engine was drawing too much current, a sign of a short circuit. The men tried to back off and untie the two loads to avoid a fire, a terrifying possibility given that the sprinkler system’s pumps were now underwater and city fire trucks were presumably out of commission. To further adjust the load, they went around the hospital shutting off scattered branch circuits serving unused fixtures and devices.

Another generator failed. This time, the workers had an idea of what caused the problem, but no spare parts to fix it. They tried to scavenge from the failed generator, but the attempted repair was unsuccessful.

The battle for the generators raged for two hours. At about two a.m. on Wednesday, August 31, 2005 — nearly forty-eight hours after Katrina made landfall near New Orleans — the last backup generator surged and then died.

The sudden silence struck Dr. Ewing Cook, lying in his office on the second floor, trying to rest, as the sickest sound of his life.

ALARMS HERALDED the power loss. They flashed and wailed on the eighth floor, where the ICU nurses had settled for the night in the rooms of their rescued patients. Nurse manager Karen Wynn stepped up on a chair and clobbered an alarm panel with her shoe to quiet it. She told her nurses to try to get some sleep.

On the seventh floor below them, the Life Care notepad computer lost its text-messaging connection. The special mattress supporting Emmett Everett’s massive body deflated. Mechanical breaths still hissed rhythmically in the rooms of patients on life support. They would cease when the battery backups on the ventilators were exhausted.